A Change in Pharmacy Is a Transition of Care

Care transitions have been identified as sentinel events because patients moving from one healthcare environment to another are at a high risk for readmissions and errors. Successful care transition models (eg, Eric A. Coleman, MD, MPh’s Care Transitions Intervention model) focus on communication tools, interprofessional teamwork, patient education, and medication reconciliation.^1,2

These models have been successfully implemented for patients transitioning between healthcare sites, and reduce readmissions and errors. Whether or not the patient has physically re­located, a change in pharmacy often goes un­recog­nized as a care transition. The same pillars of successful care site transitions (ie, communication, teamwork, patient education, and medication reconciliation) need to be applied to pharmacy service transitions to improve outcomes and reduce errors.

Challenges with Transitions of Care

Patients with chronic conditions (eg, hypertension, diabetes, asthma, heart failure, and human immunodeficiency virus [HIV]) often have more regular interactions with their pharmacy than with their medical providers. Relationships between patients and pharmacists and pharmacy staff can lead to improved outcomes.³ In addition to filling and dispensing medications, pharmacists provide medication therapy management, comprehensive medication review, vaccinations, and smoking-cessation services. These pharmacy services lead to an understanding of individual patient needs. Pharmacists and their staff also are aware of insurance or billing nuances, language preferences, delivery preferences, auto-refill services, supportive family and physician office contacts for communication about patient care, and can identify routinely refilled versus refilled-as-needed medications on the patient’s profile. When medications are transferred to a new pharmacy, this information about the patient and their care is rarely transferred along with the medications.

Changing pharmacies unnecessarily can lead to a loss of expertise, and institutional knowledge about a patient. There is very little literature available regarding outcomes of patients who have changed pharmacy services. In ambulatory care settings, however, there have been many anecdotes. For example, in one ambulatory HIV clinic, a patient on a ritonavir, atazanavir, and tenofovir/emtricitabine regimen was required to change pharmacies by his insurance provider. His insurance provider also required the use of a mail-order specialty pharmacy, when the patient had successfully been receiving deliveries from a local, HIV-specialty community pharmacy for 4 years. During the transfer, the patient’s new mail-order pharmacy requested new prescriptions, and inadvertently requested ritonavir gel capsules—which must be refrigerated—rather than ritonavir tablets, which is what the patient had been receiving from his previous pharmacy. The first delivery from the new mail-order pharmacy arrived at the patient’s home with a large, cooling packet that required immediate refrigeration. The patient had not disclosed his HIV status to his housemates, who accepted the delivery and opened the package to refrigerate it. As a result, this patient’s HIV status was disclosed to his housemates, and the patient’s anxiety and housing status concerns were markedly elevated because of the unnecessary change in pharmacy services. Careful medication reconciliation, to avoid the ritonavir formulation switch, as well as communication between the new pharmacy and patient may have been precautions to ensure accuracy and confidentiality of this patient’s information.

Transition-Related Medication Errors

The literature that is available does describe significant discrepancies between medication lists in the electronic medical records of prescriber offices, and in community pharmacy medication pro­files.^4,5 Studies comparing medication profiles between prescriber offices and pharmacies noted that nearly 90% of the patients had ≥1 discrepancies noted.^4,5 Studies comparing patient- and caregiver-generated medication lists also note discrepancies with medical office medication lists.⁶ The sources of these discrepancies included prescriptions from outside prescribers or hospitals, active refills in the pharmacy for medications that were discontinued by the clinic, patients discontinuing medications, and over-the-counter medication use.⁵ Understanding that these discrepancies are common is important when considering pharmacy care transitions. Prescriptions sent from a prescriber’s office to a new pharmacy may omit medications prescribed by other offices. Transferring prescriptions from one pharmacy to another may result in the transfer of prescriptions that the prescriber’s office has discontinued. In addition, it is important to note that pharmacies need to have active refills on a prescription to be able to successfully transfer that prescription to a new pharmacy. Some prescriptions may be omitted from a transfer if there are no refills remaining on that prescription. In this case, the new pharmacy would need a new prescription from the prescriber.

Accommodating Necessary Transitions

There are times when changes in pharmacy services are warranted, and in the best interest of patients. From what we have learned from successful care transition models, applying communication, patient education, interprofessional teamwork, and medication reconciliation to each of these pharmacy changes is a strategy for reducing errors. These pillars can be implemented in pharmacy transitions in a similar way to how they are applied to other care transition models.

How do we implement these strategies for patients who are considering a transition in their pharmacy services? The first step is to recognize that this is a transition that needs attention to avoid errors and poor outcomes. Prescriber offices need to identify personnel (eg, the prescribers, clinic-based pharmacists, nurses, medical assistants, case managers, or peer navigators) who can work with patients and their pharmacies to make this transition successful. Employees who are familiar with the various pharmacy services in the area, understand pharmacy insurance benefits, and have a relationship with the patient would be ideal candidates for leading this pharmacy transition team. During the pharmacy transition process, this team leader would use the aforementioned pillars to ensure that the transition is justified, that the change will lead to improved access to medication for the patient, and that medication lists in the clinic, patient home, and pharmacy are reconciled.

Future Considerations

Studies are needed to evaluate the impact pharmacy transitions have on patient outcomes, and to determine whether applying care transition tools will lead to improved outcomes. Based on anecdotes and studies identifying discrepancies between community pharmacies and clinic offices, the potential for errors during pharmacy transitions is high. In addition, there is pressure from insurance providers and pharmacy benefit management companies for patients to use specialty or contracted pharmacies, especially for high-cost medications. Although these pharmacy services may provide cost-savings for the insurer, the potential for error and poor patient outcomes as a result of the patient changing to these preferred pharmacies needs to be evaluated.

In the meantime, healthcare providers can improve their awareness of the impact a change in pharmacy has on a patient by including an evaluation of the patient pharmacy services, and how well or poorly those services are working for the patient, in the medication reconciliation process. If a change in pharmacy is warranted, consider a care transition team approach to ensure optimal outcomes.

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References

1. Radhakrishnan K, Jones TL, Weems D, et al. Seamless transitions: achieving patient safety through communication and collaboration. J Patient Saf. 2015 Mar 16 [Online ahead of print].
2. Gilmore V, Efird L, Fu D, et al. Implementation of transitions-of-care services through acute care and outpatient pharmacy collaboration. Am J Health Syst Pharm. 2015;72:737-744.
3. McCullough MB, Petrakis BA, Gillespie C, et al. Knowing the patient: a qualitative study on care-taking and the clinical pharmacist-patient relationship. Res Social Adm Pharm. 2015 Apr 27 [Online ahead of print].
4. Robinson CA, Cocohoba J, MacDougall C, et al. Discordance between ambulatory care clinic and community pharmacy medication databases for HIV-positive patients. J Am Pharm Assoc (2003). 2007;47:613-615.
5. Tulner LR, Kuper IM, Frankfort SV, et al. Discrepancies in reported drug use in geriatric outpatients: relevance to adverse events and drug-drug interactions. Am J Geriatr Pharmacother. 2009;7:93-104.
6. Coletti DJ, Stephanou H, Mazzola N, et al. Patterns and predictors of medication discrepancies in primary care. J Eval Clin Pract. 2015 May 29 [Online ahead of print].